What is the first step in managing a patient with a stab wound in the anterior neck who is alert but has hypoxemia with an oxygen saturation of 82%?

Emergency Airway Management for Anterior Neck Stab Wound with Hypoxemia

First-Line Intervention

Immediate cricothyroidotomy is the first intervention required for a patient with an anterior neck stab wound and severe hypoxemia (oxygen saturation 82%) to secure the airway and prevent mortality. 1

Anterior neck stab wounds can cause rapid airway compromise through:

• Direct tracheal injury
• Expanding hematoma
• Edema of surrounding tissues
• Potential for complete airway obstruction

Rationale for Cricothyroidotomy

Cricothyroidotomy is preferred over other airway interventions for several critical reasons:

1. Direct access below the injury: Provides a secure airway distal to the potential site of injury
2. Speed of execution: Can be performed rapidly in this life-threatening situation
3. Avoids manipulation of injured area: Endotracheal intubation could worsen bleeding or convert partial obstruction to complete obstruction
4. Addresses severe hypoxemia: Oxygen saturation of 82% indicates imminent respiratory failure requiring immediate intervention 2

Procedure for Emergency Cricothyroidotomy

1. Identify the cricothyroid membrane using the laryngeal handshake technique
2. Make a transverse stab incision through the cricothyroid membrane
3. Turn the blade 90° (sharp edge toward feet)
4. Slide a bougie along the blade into the trachea
5. Railroad a lubricated cuffed tube (5.0-6.0mm ID) into the trachea
6. Inflate cuff, ventilate and confirm placement with capnography
7. Secure the tube 2

If the cricothyroid membrane is impalpable:

• Make a large midline vertical incision
• Use blunt dissection with fingers to separate tissues
• Identify and stabilize the larynx
• Proceed with technique as above 2

Why Other Options Are Inadequate

• Oxygen mask: Inadequate for severe airway compromise; doesn't secure the airway
• Endotracheal intubation: High risk of failure and potential to worsen injury; may be impossible due to distorted anatomy
• Tracheostomy: Takes too long in an emergency situation; requires more extensive dissection

Post-Cricothyroidotomy Management

1. Apply high-flow oxygen via the cricothyroidotomy tube
2. Target oxygen saturation of 94-98% 2
3. Obtain arterial blood gas analysis
4. Arrange immediate surgical consultation for definitive management
5. Consider post-intubation recruitment maneuvers if hemodynamically stable 2
6. Monitor for complications: bleeding, subcutaneous emphysema, pneumothorax

Critical Considerations

• Speed is essential: Delay may lead to complete airway obstruction and death
• Minimal manipulation: Avoid excessive movement of the neck to prevent worsening injury
• Vascular injuries: Major vessels in the neck may be injured and require immediate attention after the airway is secured
• Long-term outcomes: Recent evidence shows that emergency cricothyroidotomy has acceptable long-term outcomes with minimal severe aerodigestive impairments 3

Pitfalls to Avoid

• Hesitating to perform cricothyroidotomy when indicated
• Attempting repeated endotracheal intubation in a difficult airway scenario
• Failing to recognize the urgency of the situation with SpO₂ of 82%
• Inadequate sedation or analgesia during the procedure
• Improper tube placement or inadequate securing of the tube

Remember that in this life-threatening scenario with anterior neck trauma and severe hypoxemia, securing the airway through cricothyroidotomy is the priority that will most effectively reduce mortality and morbidity.